What is the recommended dosing for Amlodipine (calcium channel blocker) in a patient with hypertension or coronary artery disease, considering factors such as age and liver disease?

Amlodipine Dosing Recommendations

Standard Adult Dosing

For most adults with hypertension or coronary artery disease, start amlodipine at 5 mg once daily and titrate to a maximum of 10 mg once daily based on blood pressure response. 1

Initial Dosing Strategy

• The usual starting dose is 5 mg once daily for hypertension, with 10 mg once daily as the maximum dose 1
• For chronic stable angina or vasospastic angina, use 5-10 mg once daily, with most patients requiring 10 mg for adequate effect 1
• For coronary artery disease, the recommended range is 5-10 mg once daily, with the majority of patients in clinical studies requiring 10 mg 1

Titration Timeline

• Wait 7-14 days between dose adjustments under normal circumstances 1
• Titrate more rapidly if clinically warranted, provided the patient is assessed frequently 1
• Do not increase the dose before 6 weeks of treatment at 5 mg once daily, as there is no advantage in early dose escalation for blood pressure control 2
• Assess blood pressure response after 4 weeks of treatment to allow adequate time for full therapeutic effect 3

Special Population Dosing

Elderly Patients

Start at 2.5 mg once daily in elderly patients and titrate cautiously, monitoring closely for adverse effects. 3, 1

• Small, fragile, or elderly patients should begin at 2.5 mg once daily 1
• Monitor specifically for orthostatic hypotension, falls, and syncope, which have increased risk in this population 3
• Check blood pressure in both sitting and standing positions to detect orthostatic changes 3
• Recheck blood pressure within 2-3 weeks after starting therapy in elderly patients 3, 4
• Blood pressure targets should be individualized, generally aiming for <140/90 mmHg in frail elderly patients 3

Hepatic Impairment

Initiate amlodipine at 2.5 mg once daily in patients with hepatic insufficiency due to decreased hepatic clearance and increased drug concentrations. 3, 1

• Amlodipine is lipophilic with decreased hepatic and overall clearance in liver disease 3
• The lower starting dose accounts for reduced drug metabolism and potential accumulation 3

Pediatric Dosing (Ages 6-17 Years)

• The effective antihypertensive dose is 2.5-5 mg once daily 3, 1
• The maximum pediatric dose is 5 mg daily, as higher doses have not been studied in this population 3, 1
• Amlodipine can be compounded into stable extemporaneous suspensions for children who cannot swallow tablets 3

When Adding to Other Antihypertensives

Combination Therapy Initiation

• When adding amlodipine to other antihypertensive therapy, start at 2.5 mg once daily 1
• The combination with ACE inhibitors or ARBs provides complementary mechanisms of blood pressure control 5
• For uncontrolled hypertension on dual therapy, adding amlodipine as a third agent (typically to an ACE inhibitor/ARB plus thiazide diuretic) achieves guideline-recommended triple therapy 5

Monitoring Parameters

Follow-up Schedule

• Recheck blood pressure within 2-3 weeks initially in elderly patients 4
• If initial response is inadequate after 2-3 weeks, consider dose adjustment with subsequent follow-up in another 2-3 weeks 4
• After blood pressure is controlled (<140/90 mmHg), subsequent follow-up can be scheduled at 4-6 weeks 4
• If blood pressure remains elevated after initial dose adjustment, monitor every 2 weeks until target is achieved 4

Blood Pressure Targets

• Target <140/90 mmHg for most patients 5
• Aim for at least a 20/10 mmHg reduction from baseline 5, 4
• For higher-risk patients, consider targeting <130/80 mmHg 5

Critical Pitfalls to Avoid

• Never use immediate-release nifedipine capsules, which should no longer be prescribed 3
• Do not combine amlodipine with non-dihydropyridine calcium channel blockers (diltiazem, verapamil) due to redundant mechanisms 3
• Do not increase doses before allowing adequate time for therapeutic effect (minimum 4 weeks, ideally 6 weeks at 5 mg) 3, 2
• Monitor carefully for peripheral edema, which is common with amlodipine and may be attenuated by adding an ACE inhibitor or ARB 5